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SAN JOAQUINTY PUBLIC HEALTH SERVICES - ENVIRONMENTA LTH DIVISION U _ GROUND STORAGE TANK PROGRAM - FEE WORKSHEE. S FACILITY SITE NAME FACILITY CONTACT NAME �Gurpal I Waterloo Food & Fuel Sidhu T P E FACILITY ADDRESS SITE PHONE # with AREA CODE XXXX XXXX 3032 E. Waterloo Road A & I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S CITY STATE ZIP CODE # of TANKS A Stockton CA 95205 at SITE 3 PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) T� FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX P XXXX XXXX S XXXXXXXXXXXXX PI APPLICANT/BILLING NAME APPLICANT CONTACT NAME L Oil Equipment Service Keith A. Tallia I C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A P.O. Box 950 209-754-1808 1994 1995 1996 - N each year applicable) XXXX XXXX XXXX XXXX XXXX T CITY STATE ZIP CODE=TYPEPLICATION San Andreas CA 95249Installation, etc.) Install TOTAL P� INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) L A NJ PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum $624.00 R REPAIR FEE (Workplan Review & Construction Inspections) 1986 1987 11988 1 1989 1990 E ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 P TANK LINING REPAIR FEE = S78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = S XXXX XXXX XXXX S XXXXXXXXXXXXX A XXXX XXXX I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S R C PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) T� FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I XXXX XXXX XXXX S XXXXXXXXXXXXX I Y TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E, FI # Tanks = 1986 1987 1988 1989 1990 (multiply # by fee for 1991 1 1992 1993 1994 1995 1996 - Al each year applicable) XXXX XXXX XXXX XXXX XXXX $ 11 TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX i XXXX I S L I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S_ Code, Section 25287 T Y # Tanks x $56.00 1988 through 1990 1991 through 1996 (Enter amount and year) S Cl PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.O. #(s) L ' 1 1 OI CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ S UTEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P� INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) L A NJ PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum $624.00 R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = S78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = S A I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S M TRANSFER FEE _ $20.00 1 S C CONSULTATION FEE _ $78.00/hr FOR OFFICE USE ONLY UNAUTHORIZED RELEASE EVALUATION = $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr i 0 TOTAL DUE 1 $624.00 w